Anatomy of Biliary tree
Common bile duct (CBD) stone (Choledocholithiasis) Choledocholithiasis is a disease of the common bile duct. The common bile duct forms at the junction of the cystic duct (from the gallbladder) and the common hepatic duct (from the liver). It drains bile into the duedenum (the first part of the small intestine).
Location of Gall stone 1. 2. 3. 4. Gallbladder (Cholecystolithiasis) Cystic duct (Cysticolithiasis) Common bile duct (Choledocholithiasis) Common hepatic duct (Hepatolitiasis)
Type of CBD stone 1. Cholesterol stones 2. Pigment stones a. Black-pigment stones b. Brown-pigment stones Risk Factor cholesterol stones include: o o o High serum cholesterol leves Increased age Female sex
o o o o
Obesity Rapid weight loss The contraceptive pill Total parenteral nutrition
pigment stones include: o o o Chronic haemolysis (red blood cell breakdown) -hereditary spherocytosis Sickle cell disease, as well as liver cirrhosis. They may also form in the bile ducts after cholecystectomy (surgical
removal of the gallbladder).
Clinical manifestation Symptoms usually do not occur unless the stone blocks the common bile duct. Symptoms that may occur include: o Abdominal pain in the right upper or middle upper abdomen that may: o Be steady o Be sharp, cramping, or dull o Spread to the back or below the right shoulder blade o Fever o Loss of appetite o Jaundice (yellowing of skin and whites of eyes) o Nausea and vomiting
How is Common Bile Duct Stone diagnosed Clinical symptom & Clinical examination Laboratory test :
Full blood count - elevated white cell count signifying infection. Liver function tests - elevated bilirubin, evidence of stasis. Blood cultures - frequently positive in cholangitis. Amylase/Lipase - may be elevated if there is an element of pancreatitis.
Imaging Abdominal CT scan
Complication
Abdominal ultrasound Endoscopic retrograde cholangiography (ERCP) Endoscopic ultrasound Magnetic resonance cholangiopancreatography (MRCP) Percutaneous transhepatic cholangiogram (PTCA)
Biliary cirrhosis Cholangitis Pancreatitis
Treatment o Surgery : ERCP and a procedure called a sphincterotomy o Laparascopic Cholecystectomy + pre op ERCP o Laparascopic cholecystectomy + intra op ERCP o Laparascopic Cholecystectomy + CBD exploration(transcystic / choledochotomy) o open cholecystectomy + CBD exploration
Surgery risk The major risk of an ERCP is the development of pancreatitis Heart and lung problems Bleeding after sphincterotomy Infection in the bile duct (cholangitis) perforation (a tear in the intestine) Over sedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.
Pathogenesis
PREDISPOSING/ NON-MODIFIALBE GENDER: FEMALE AGE: 40 MULTIPAROUS PRECIPITATING/ MODIFIABLE LIFESTYLE FERTILE DISEASE
AGEING ESTROGEN IN WOMEN USE OF ORAL CONTRACEPTIV ES
MEDICATION SUCH AS CLOFIBRATE
ILEAL DISEASE INTESTINAL BYPASS SURGERY
PREGNANCY STARVATION RAPID WEIGHT LOSS
FATTY LIVER
SERUM CHOLESTEROL LEVELS
BILE ACID SYNTHESIS
MALABSORPTION OF BILE SALTS
BILE COMBINES WITH CHOLESTEROL IN THE LIVER
EXCRETION OF GALL BLADDER SLUDGE
HEPATIC SECRETION OF SUPER SATURATED
EMULSIFICATION OF CHOLESTEROL
SLUGGISH BILE FLOW
CHEMICAL IRRITATION TO BALLDER
PRECIPITATION OF CHOLESTEROL/PI GMENT CRYSTALS CHOLESTEROL/PIGM ENT STONE FORMATION IN THE GALL BLADDER
CHOLECYS TITIS
INFLAMMATION OF THE GALLBLADDER
CHOLELITHIASIS
STONE FORMATION IN THE HEPATIC DUCT DISLODGEME NT OF STONE IN THE COMMON
NAUSEA/VOMITING FEVER CHILLS PAIN ALTERATION IN THE ABSORPTIVE CHARACTERISTIC OF THE MUCOSAL LAYER EXCESSIVE BELCHING ABDOMINAL DISTENTION PAIN ABSORPTION OF WATER AND BILE SALTS CHOLEDOCOLITHIASIS OBSTRUCTION OF GALL STONES AND INFLAMMATIO N OF THE COMMON BILE DUCT
SIGNS/SYMPTOMS MANIFESTED ON THE PATIENT: BILIARY COLIC
SUPER SATURATION OF CHOLESTEROL IN THE BILE ON THE GALL BLADDER
JAUNDICE YELLOWISH CONJUNCTIVA TENDERNESS IN THE RIGHT UPPER QUADRANT OF THE ABDOMEN
